Nothing New Under the Sun

The World still hurts.

Considering current global events our planet seems a panoply of despair, a train wreck of evil choices. We feel wounded, flabby and impotent, and we struggle to understand. We look for answers as to how we can make things better, both on a global scale, and in our own back yards. One of the solutions, of course, is right, myopically, in front of us, and is an echoing sentiment that can be heard from the moment man first began to document history.

If you look carefully, if you take the time, you can see a gossamer thin strand, lacing and linking through the past. Woven throughout the ages of human history, in amongst the warp of the words of great and influential figures and the weft of fiction, is this thread; a sentiment that keeps glinting its colour and its disposition, time and time again.

We occasionally read, listen, perhaps nod in agreement, but how often do we take the time to reflect upon it? A luminous little thought, a meditation clarified over centuries, staying no less relevant now than when it was first recorded on paper. The thought goes something like this –

the mark of a truly civilised human is the way that they treat those inferior to them’

It only finds its way onto the virtual pages of Life in the Fast Lane, because here we are the repository for many of the happenings in the critical care world, a sort of thermomix for ideas, and we like to occasionally step tentatively into the hall of mirrors, and take a piercing look at the people we are, and the attitudes we bear along with us. How do we, as individuals, treat those who are not as strong as us, who are weaker, or somehow positioned downwind on the social pecking order? Our Emergency Departments are seething with people, many of whom are less fortunate, in lesser jobs, sometimes even desperate individuals, jobless, luckless, the drug-addicted and the lost. And an even subtler phenomenon, how do we interact with some of the patients with chronic illnesses, such as obesity? Do they fall under the umbrella of what the modern philosopher Jean Harvey characterises as ‘civilised oppression’?

Moreover, how do we conduct ourselves with those whose roles are perhaps perceived to be subordinate to ours? There would be little argument that the world of critical care is evolving in an admirably egalitarian way, however there are still countless episodes, everyday, where somebody less knowledgeable is belittled, one of the cogs of the working machinery of healthcare is ignored, we diminish the opinions of others through the ether, or we simply lash out at those most easily wounded, as a response to a dwindling level of respect laid out for us by our own managerial types. View the unfortunate occasional interactions between specialty teams and junior doctors, phone answering ED consultants to junior staff trying to send patients in from elsewhere, or even the way we listen to a handover.

And also, as an aside, this concept IS the solution to world peace, but let us not digress into trivialities here.

However this little piece is not a conveyance for my opinions, it is a chance to reconnoiter this singular notion, voiced by a good many figures who knew a thing or two about the inner workings of humanity, lain down repetitively like a palimpsest. So we should hear from just a few of them:

Seneca (the Younger) – Rome’s leading intellectual in the first century of the Common Era. A Stoic, a humourist, a statesman and a dramatist.

There is a proverb: ‘You have as many enemies as you have slaves.’ But in truth we make them our enemies. We abuse them as if they were beasts of burden. When we recline for dinner, one wipes our spittle, another picks up the scraps and crumbs thrown down by drunkards. The point of my argument is this. ‘Treat your inferior as you would like to be treated’”.

The Earl of Chesterfield, (Philip Stanhope), statesman and essayist, in published letters to his son (1748)

‘The characteristic of a well-bred man is, to converse with his inferiors without insolence, and with his superiors with respect, and with ease.’

Samuel Johnson – lexicographer, poet and essayist says it thus

The true measure of a man is how he treats someone who can do him absolutely no good.’

In 1910, the Rev. Charles Bayard Miliken, of the Methodist Episcopal Church, Chicago

It is the way one treats his inferiors more than the way he treats his equals which reveals one’s real character.’

Sirius Black, a brave, clever and energetic pure blood wizard (according to Albus Dumbledore), misunderstood for many years, and who received the education of life in Azkaban

If you want to know what a man’s like, take a good look at how he treats his inferiors, not his equals.’

Repeatedly and anew, we are reminded of what can make us rise up over effrontery, over our mediocrity, our incivility, and sit lightly upon the heavy dark mass of society. Every interaction we have with another human, on this vast concatenated web of a life we lead, is an opportunity to improve our measure as a civilised being, and thus improve it, in some inestimable way. It’s not always easy, but the opportunities are there, every single day of our interacted lives.

Simplistic? Yes. Moralistic? Yes. But an incontrovertible truth? Yes.

And although this was written to give you a moment’s fleeting reflection, we shall now allow the filmy nature of the words to pop and dissipate, and let’s have a little fun, inviting our quoted people of today to a dinner party, sit them down, and ask them to expound one of their lesser known quotations, for the amusement of us all back here in reality. (I didn’t invite the Reverend, not really knowing him, and not sure he’d approve of the company)

Seneca, what is your opinion on bathhouses?

“I would die if silence were as necessary to study as they say. I live just above the bath house.”

“Consider all the hateful voices I hear! When the brawny men exercise with their lead weights, I hear their groans and gasps. Or when someone else comes in to get a vulgar massage: I hear the slap of a hand on his shoulders. Add those who leap into the pool with a huge splash. Beside these, who at least have normal voices, consider the hair plucker, always screeching for customers, and never quiet except when he’s making someone else cry.”  

Earl Chesterfield, how do you perceive of marriage?

‘Marriage is the cure of love, and friendship the cure of marriage.’

Oh, I see.

Samuel Johnson, another drink?

‘One of the disadvantages of wine is that it makes a man mistake words for thoughts.’ 

Sirius, the others at the table here have been rather flippant.  Do you have any closing remarks?

“We’ve all got both light and dark inside of us. What matters is the part we choose to act on. That’s who we really are.” 

Well at least somebody can take this post seriously.

The sentiment remains, however, that the only way to better the microcosm of your small world, as well as this planet Earth, as it stands, is to treat every individual, no matter their station, with respect.

 

Carry on the #FOAMlove.

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REMI 1977. Efecto de la eritropoyetina y del umbral de transfusión en la recuperación neurológica del TCE cerrado

Artículo originalEffect of Erythropoietin and Transfusion Threshold on Neurological Recovery After Traumatic Brain Injury: A Randomized Clinical Trial. Claudia S. Robertson, MD; H. Julia Hannay, PhD; José-Miguel Yamal, PhD; et al. JAMA 2014; 312(1): 36-47. [Resumen] [Artículos relacionados] [Web JAMA]
       
Introducción: Los pacientes con TCE desarrollan a menudo anemia que puede causar lesión cerebral secundaria. La eritropoyetina se ha empleado para tratar esta anemia porque en modelos experimentales, además de mejorar la anemia, tiene un efecto neuroprotector y puede mejorar la supervivencia. Esto último se ha visto también en algunos ensayos clínicos de pequeño tamaño. La anemia también se ha tratado con transfusiones de concentrado de hematíes, pero esto tiene sus complicaciones  y en diversos estudios se ha demostrado que la mayoría de los pacientes críticos no se benefician de mantener un nivel elevado de hemoglobina. Este ensayo clínico, con un diseño factorial 2 x 2, se diseño para comparar los efectos de la administración de eritropoyetina y las transfusiones con dos umbrales diferentes (7 y 10 g/dL de Hb) en la recuperación neurológica.
     
ResumenSe trata de un ECA de 200 pacientes con TCE cerrado e incapacidad para responder a órdenes, que fueron asignados a tratamiento con eritropoyetina o placebo y a transfusión con un umbral de 7 o 10 g/dL de Hb. Los desenlaces primarios fueron el fallo de la eritropoyetina en mejorar la recuperación neurológica en un 20% y la mejoría de la recuperación neurológica con un umbral de transfusión de 10 g/dL, sin aumentar las complicaciones, ambos a los 6 meses. La dosis de eritropoyetina se disminuyó durante el estudio, tras 74 pacientes, debido a los resultados del estudio EPO Stroke. La recuperación neurológica se midió mediante la escala GOS dicotomizada como favorable (buena recuperación o discapacidad moderada) y desfavorable (discapacidad grave, estado vegetativo o muerte). No hubo interacción entre los grupos de eritropoyetina y transfusión. Comparados con placebo (resultado favorable en un 38,2%, IC 95% 28,1%-49,1%), los dos regímenes de eritropoyetina fueron fútiles. La tasa de buen resultado neurológico con un umbral de transfusión de 7 g/dL fue del 42,5% y del 33,0% para el de 10 (IC 95% -0,06 a 0,25; P = 0,28). Con el umbral de 10 hubo mayor incidencia de fenómenos tromboembólicos (21,8% contra 8,1%, OR 0,32; IC 95% 0,12 a 0,79, P = 0,009).
       
Comentario: Elevar la hemoglobina bien mediante el uso de eritropoyetina, bien mediante transfusión, no ha resultado útil para mejorar la supervivencia con buen estado neurológico en el TCE cerrado en este estudio. Además, el mayor número de transfusiones necesario para mantener el umbral de 10, hace que las complicaciones sean más frecuentes. Varios ensayos previos ya han mostrado que el umbral de 7 g/dL de Hb es seguro en varios tipos de pacientes críticos. Los resultados de este ensayo confirman esos resultados y agregan un nuevo tipo de pacientes en los que se puede aplicar la estrategia restrictiva.
      
Ramón Díaz-Alersi
Hospital U. Puerto Real, Cádiz.
© REMI, http://medicina-intensiva.com. Julio 2014

Enlaces:
  1. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Carson JL, Carless PA, Hebert PC. Cochrane Database Syst Rev 2012; 4: CD002042. [PubMed
  2. Transfusion strategies for acute upper gastrointestinal bleeding. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C. N Engl J Med 2013; 368: 11-21.[PubMed] [Texto completo] [REMI
  3. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH, Mauad T, Roquim AC, Sundin MR, Leão WC, Almeida JP, Pomerantzeff PM, Dallan LO, Jatene FB, Stolf NA, Auler JO Jr. JAMA 2010; 304: 1559-1567. [PubMed] [Texto completo] [REMI
  4. Liberal or restrictive transfusion in high-risk patients after hip surgery. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J; FOCUS Investigators. N Engl J Med 2011; 365: 2453-2462. [PubMed] [Texto completo] [REMI
  5. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. Rohde JM, Dimcheff DE, Blumberg N, Saint S, Langa KM, Kuhn L, Hickner A, Rogers MA. JAMA 2014; 311: 1317-1326. [PubMed][Texto completo] [REMI]
Búsqueda en PubMed
  • Enunciado: Umbral de transfusión y seguridad en el paciente crítico 
  • Sintaxis: transfusion threshold AND safety AND (critical care OR critically ill) 
  • [Resultados]
      

Talking, Teaching & Technology – Victoria Brazil @SocraticEM at St Emlyn’s

St Emlyns - Meducation in Virchester #FOAMed

You probably know by now that SMACC Gold was awesome. There simply aren’t enough superlatives to describe the magnitude of inspiration on offer from the world’s finest critical care speakers.  Putting together a programme like SMACC’s was an incredible feat – where would you even start?   The answer to that question comes naturally – […]

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